Systems, devices, and methods for securing tissue using snare assemblies and soft anchors

ABSTRACT

Systems, devices, and methods are provided for securing soft tissue to bone. One exemplary embodiment of a surgical soft tissue repair device includes a snare assembly coupled to a soft anchor in which the soft anchor has a first, unstressed configuration that can be used to insert the anchor into bone and a second, anchoring configuration that can be used to fixate the anchor in the bone. The snare assembly can be configured to actuate the anchor from the first configuration to the second configuration, and it can also be used to engage and approximate tissue by drawing the tissue closer to the anchor fixated in the bone. The snare assembly can be used in conjunction with a number of different anchor configurations, and other exemplary systems, devices, and methods for use with soft tissue repair are also provided.

CROSS REFERENCE TO RELATED APPLICATION

The present application is a divisional of U.S. application Ser. No.13/465,376, filed May 7, 2012, and entitled “SYSTEMS, DEVICES, ANDMETHODS FOR SECURING TISSUE USING SNARE ASSEMBLIES AND SOFT ANCHORS,”which is hereby incorporated by reference in its entirety.

FIELD

The present disclosure relates to systems, devices, and methods forsecuring soft tissue to bone, and more particularly relates to securingsoft tissue while minimizing or eliminating the tying of knots totension and secure the tissue.

BACKGROUND

A common injury, especially among athletes and people of advancing age,is the complete or partial detachment of tendons, ligaments, or othersoft tissues from bone. Tissue detachment may occur during a fall, byoverexertion, or for a variety of other reasons. Surgical interventionis often needed, particularly when tissue is completely detached fromits associated bone. Currently available devices for tissue attachmentinclude screws, staples, suture anchors, and tacks. Currently availabledevices for patients of advancing age can be particularly insufficientdue to soft and weak bones leading to inadequate suture-to-anchorfixation.

Arthroscopic knot tying is commonly practiced in shoulder rotator cuffand instability procedures. Typically, an anchor loaded with suture isfirst attached to bone. The suture is normally slidably attached to theanchor through an eyelet or around a post, such that a single length ofsuture has two free limbs. One limb of the suture is passed through softtissue to be repaired such as a tendon or labrum. The two ends of thesuture are then tied to each other, thereby capturing the soft tissue ina loop with the anchor. Upon tightening the loop, the soft tissue isapproximated to the bone via the anchor.

Surgeons typically tie the suture ends using a surgical sliding knotsuch as the Tennessee Slider or Duncan Loop. After advancing the knotdistally to tighten the loop, a number of additional half hitches orother knots are tied in an effort to secure the new location of thesliding knot. The additional knots are needed because a conventionalsliding knot used in current repair constructs does not provide thenecessary protection against loosening or slippage, especially whentension is placed primarily on the limbs of the loop. The generallyaccepted practice is to follow the sliding knot with at least threereversed half hitches on alternating posts of the suture.

Before one or more half hitches or other knots can be added to thesliding knot, however, there exists a potential for the sliding knot toslip, that is, for the loop to enlarge as the tissue places tension onthe loop. This has been referred to as “loop security” and canreportedly occur even in the hands of very experienced surgeons.Sometimes, even fully-tied knots may slip. In addition to this “loopsecurity” problem, conventional knots typically have an overall sizethat can be obstructive or intrusive, especially in tight joints, whichmay damage cartilage or other tissue by abrasion with the knot.

Suture anchor systems with sliding and locking knots for repairing tornor damaged tissue include U.S. Pat. No. 6,767,037 by Wenstrom, Jr. Othersuture anchor systems suited especially for meniscal repair aredisclosed in U.S. Pat. No. 7,390,332 by Selvitelli et al. and areutilized in the OmniSpan™ meniscal repair system commercially availablefrom DePuy Mitek Inc., 325 Paramount Drive, Raynham, Mass. 02767.Screw-type anchors normally require anchor attachment before operatingsutures, which can lead to challenges related to the connection betweenthe suture and the tissue.

There are a number of suture implant systems which proclaim to be“knotless,” that is, to not require a surgeon to tie a knot duringsurgery. Many such systems control tension on tissue by the depth towhich an anchor is driven into bone. U.S. Pat. Nos. 5,782,864 and7,381,213 by Lizardi disclose certain types of suture anchors thatcapture a fixed-length loop of suture. Adjustable loop knotless anchorassemblies utilizing an anchor element inserted into a sleeve aredescribed by Thal in U.S. Pat. Nos. 5,569,306 and 6,045,574 and in U.S.Patent Application Publication No. 2009/0138042. Other systems havingclamps or other locking mechanisms include U.S. Pat. No. 5,702,397 byGoble et al. and U.S. Patent Application Publication No. 2008/0091237 bySchwartz et al. Present, so-called “knotless” designs, however,generally suffer from inadequate suture-to-anchor fixation and/orinadequate anchor-to-bone fixation, among other deficiencies.

It is therefore desirable to provide systems, devices, and methods foruse in soft tissue repair that are robust and strong, yet minimize oreliminate the number and size of knots to be tied by a surgeon,particularly during arthroscopic repair procedures. It is also desirableto provide systems, devices, and methods that minimize the number ofcomponents a system needed to secure an anchor in bone and approximatetissue to that bone. There is also a need for suture anchors and methodsof deploying such anchors that minimizes the surgical trauma associatedwith the implantation of an anchor of a given size.

SUMMARY

Systems, devices, and methods are generally provided for securing softtissue to bone. In one exemplary embodiment a surgical soft tissuerepair device includes a snare assembly coupled to a soft anchor. Thesoft anchor can be formed of a flexible construct with a plurality ofopenings formed therein. The anchor can be configured to have a first,unstressed configuration, for example to insert the anchor into a bone,and a second, anchoring configuration to fix the anchor to the bone. Theanchor can have a first length and a first diameter in the firstconfiguration and a second length that is less than the first length anda second diameter that is greater than the first diameter. The snareassembly can have a collapsible snare at one end and at least oneelongate filament extending therefrom. The filament includes a terminalend that is opposite the collapsible snare and the filament can passthrough openings in the soft anchor to couple the snare assembly to thesoft anchor such that the soft anchor is at an intermediate location onthe elongate filament between the snare and the terminal end. The softanchor and snare can be configured such that the soft anchor isreconfigurable from its first, unstressed configuration to its second,anchoring configuration by the application of tension to the filament.

In some embodiments the soft anchor can be a cannulated suture with acentral lumen. Further, the plurality of openings can include a firstopening on a distal portion of the soft anchor and a second opening on aproximal portion of the soft anchor, with each of the two openings beingin communication with the central lumen. In one, non-limitingconfiguration, the filament can pass into the second opening, throughthe lumen, and out of the first opening. In some embodiments the firstand second openings can be on the same side of the soft anchor.

In some other embodiments the soft anchor can include a plurality oftransverse bores extending therethrough along the length of the softanchor. In such an embodiment, the anchor can be cannulated ornon-cannulated. The plurality of openings can include opposed pairedopenings, and each opposed paired opening can communicate with one ofthe transverse bores. In one, non-limiting configuration, the anchor caninclude at least four transverse bores and the filament can pass intoand out of each transverse bore through the opposed paired openings.

In yet some other embodiments the soft anchor can be a crocheted sutureanchor, and the filament can extend through openings defined betweenfilament limbs of the crocheted suture anchor along the length thereof.

In its anchoring configuration, the soft anchor can have a diameter thatis at least about 20% greater than its diameter in the unstressedconfiguration. The snare assembly can be formed of a double filamentloop such that the filament has first and second filament limbs. Aremovable, flexible sleeve can be included as part of the device toremovably encapsulate at least a portion of the filament.

In another exemplary embodiment a surgical soft tissue repair deviceincludes an anchor, a snare assembly, and a connecting filament coupledto the snare assembly and effective to connect the snare assembly to theanchor. The anchor can be configured to be fixated in bone, and it canhave at least one bore extending therethrough. The snare assembly canhave a collapsible snare at one end and at least one elongate filamentextending therefrom, with the filament having a terminal end that isopposite the collapsible snare. The connecting filament can be disposedin the bore or on a side of the bore distal to the snare assembly, andcan be configured to be secured to the anchor such that the anchor ispositioned at an intermediate location on the elongate filament betweenthe collapsible snare and the terminal end.

One exemplary embodiment of a surgical repair method includes insertinga flexible anchor into a hole in a bone at a location proximate todetached soft tissue. The anchor can have first and secondconfigurations, with the first configuration having a first length and afirst diameter and the second configuration having a second length thatis less than the first length and a second diameter that is greater thanthe first diameter. The anchor can be coupled to a snare assembly thatpasses through at least a portion of the anchor, with the snare assemblyhaving a collapsible snare at one end thereof and at least one elongatefilament extending therefrom. The elongate filament can have a terminalend that is opposite the collapsible snare. The method can also includetensioning the filament to move the anchor from the first configurationto the second configuration to fix the anchor relative to bone, passingat least one of the snare and the terminal end of the elongate filamentthrough at least a portion of the detached tissue, inserting theterminal end of the filament through the snare, collapsing the snarearound the filament, and sliding the collapsed snare toward the softtissue to apply tension to filament between the anchor and the tissue tobring the tissue into proximity with the bone.

The first and second configurations can be defined by the second lengthbeing at least about 50% less than the first length. The first andsecond configurations can also be defined such that the second diameteris at least about 20% greater than the first diameter. In someembodiments the flexible anchor can be a cannulated anchor with a lumenextending therethrough. Such an anchor can include a first opening atits proximal end and a second opening at its distal end, with each ofthe first and second openings being in communication with the lumen. Insome embodiments the flexible anchor can have one or more plurality ofbores extending transversely therethrough along the length of theflexible anchor.

BRIEF DESCRIPTION OF DRAWINGS

This invention will be more fully understood from the following detaileddescription taken in conjunction with the accompanying drawings, inwhich:

FIG. 1 is a schematic view of one exemplary embodiment of a snareassembly for use as part of a surgical soft tissue repair device;

FIG. 2A is a schematic view of a snare assembly having a noose formedtherein with first and second filament limbs extending to a second end;

FIGS. 2B and 2C are sequential views of the snare assembly of FIG. 2Awith the first and second filament limbs passed through the noose toform a snare or cinch noose;

FIGS. 3A-3D are sequential views of another exemplary embodiment forforming a snare assembly having a snare at a first end and first andsecond filament limbs extending to a second end;

FIG. 4 is a schematic view of one exemplary embodiment of a surgicalsoft tissue repair device that includes the snare assembly of FIG. 1 andone embodiment of an anchor;

FIGS. 5A-5H are sequential views of one exemplary embodiment for usingthe surgical soft tissue repair device of FIG. 4 to secure tissue tobone;

FIG. 6 is a schematic view of another exemplary embodiment of a surgicalsoft tissue repair device that includes the snare assembly of FIG. 1 andanother embodiment of an anchor;

FIGS. 7A-7H are sequential views of one exemplary embodiment for usingthe surgical soft tissue repair device of FIG. 6 to secure tissue tobone;

FIG. 8 is a schematic view of still another exemplary embodiment of asurgical soft tissue repair device that includes the snare assembly ofFIG. 1 and still another embodiment of an anchor;

FIGS. 9A-9H are sequential views of one exemplary embodiment for usingthe surgical soft tissue repair device of FIG. 8 to secure tissue tobone;

FIG. 10 is a schematic view of yet another exemplary embodiment of asurgical soft tissue repair device that includes the snare assembly ofFIG. 1 and yet another embodiment of an anchor; and

FIGS. 11A-11J are sequential views of one exemplary embodiment for usingthe surgical soft tissue repair device of FIG. 10 to secure tissue tobone.

DETAILED DESCRIPTION

Certain exemplary embodiments will now be described to provide anoverall understanding of the principles of the structure, function,manufacture, and use of the devices and methods disclosed herein. One ormore examples of these embodiments are illustrated in the accompanyingdrawings. Those skilled in the art will understand that the devices andmethods specifically described herein and illustrated in theaccompanying drawings are non-limiting exemplary embodiments and thatthe scope of the present invention is defined solely by the claims. Thefeatures illustrated or described in connection with one exemplaryembodiment may be combined with the features of other embodiments. Suchmodifications and variations are intended to be included within thescope of the present invention. Further, in the present disclosure,like-numbered components of the embodiments generally have similarfeatures. Additionally, to the extent that linear or circular dimensionsare used in the description of the disclosed systems, devices, andmethods, such dimensions are not intended to limit the types of shapesthat can be used in conjunction with such systems, devices, and methods.A person skilled in the art will recognize that an equivalent to suchlinear and circular dimensions can easily be determined for anygeometric shape. Sizes and shapes of the systems and devices, and thecomponents thereof, can depend at least on the anatomy of the subject inwhich the systems and devices will be used, the size and shape ofcomponents with which the systems and devices will be used, and themethods and procedures in which the systems and devices will be used.

The figures provided herein are not necessarily to scale. Still further,to the extent arrows are used to describe a direction of movement, thesearrows are illustrative and in no way limit the direction the respectivecomponent can or should be moved. A person skilled in the art willrecognize other ways and directions for creating the desired result.Additionally, a number of terms may be used throughout the disclosureinterchangeably but will be understood by a person skilled in the art.By way of non-limiting example, the terms suture and filament may beused interchangeably.

Systems, devices, and methods for soft tissue repair are generallyprovided and they generally involve the use of surgical filaments thatare configured in a variety of manners to minimize and/or eliminate thetying of knots during a surgical procedure. The systems and devicesdescribed herein provide superior strength for use in a number ofdifferent surgical procedures, such as rotator cuff and instabilityrepair procedures and other types of tendon and tissue repairprocedures. The systems, devices, and methods described herein alsoallow for constructs used to repair tissue to be made completely offlexible members, thereby minimizing or eliminating trauma that canresult from using harder materials for tissue repair. The systems anddevices provided herein further allow for both improved and newprocedures for soft tissue repair. For example, the systems and devicesprovided herein can be used to both secure an anchor in bone and drawtissue toward the bone for attachment thereto.

FIG. 1 illustrates one exemplary embodiment of a snare assembly 20 foruse in conjunction with a number of different configurations of softanchors, some non-limiting examples of which are provided and discussedbelow with respect to FIGS. 4-11J. As shown in FIG. 1, the snareassembly 20 can be generally flexible, can include a snare 30 formed ona first end 22, and can have a terminal end 24 opposite the first end22, with an intermediate portion extending therebetween. The terminalend 24 can be configured to pass through an opening 32 in the snare tocreate a tensionable construct so the snare assembly can draw two ormore objects, such as tissue and bone, closer together, as described ingreater detail below. Further, in embodiments in which the snareassembly 20 is coupled to an anchor having both an unstressedconfiguration for insertion and an anchoring configuration for placementof the anchor in bone, the snare assembly 20 can be used to actuate thetransition of the anchor from its unstressed configuration to itsanchoring configuration, as also described in greater detail below.

Optionally, a flexible sleeve 50 can be provided for encapsulating atleast a portion of the assembly 20. As shown in FIG. 1, the sleeveencapsulates a portion of the assembly 20 starting at the terminal end24 and extending toward the first end 22. In other embodiments thesleeve can extend more proximal than the terminal end 24. Aconfiguration of this nature can aid a surgeon in pulling the snareassembly 20 through a portion of the body by providing extra length ontowhich he or she can grasp. Preferably, once the assembly 20 isimplanted, the sleeve 50 can extend outside of a body as well as outsideof a cannula placed in the body so the sleeve 50 can be easily removed.The sleeve 50 can have a generally cylindrical configuration and can beflexible to allow it to bend as shown in various embodiments providedherein. The sleeve 50 can be useful when passing the assembly 20 throughobstructions such as an anchor and/or tissue for a number of reasons.The sleeve 50 can be configured to have a smoother surface that isbetter configured to pass through a soft anchor and tissue, thusreducing the possibility of fraying the soft anchor or causing trauma tothe tissue. Still further, because the sleeve 50 can encapsulate aplurality of filament limbs, the sleeve 50 can ease filament managementby maintaining the filaments within the enclosed sleeve 50. The sleeve50 can be removable, and thus it can be removed at any time during theprocedure, or at the conclusion of the procedure.

FIGS. 2A-2C illustrate one exemplary method of forming a snare assembly.As shown in FIG. 2A, the snare assembly 120 can be a filament having anoose 160 and noose limbs 164, 166. The noose 160 defines a centralopening 162 and secondary openings 161 and 163 formed from a half hitchplus one additional throw of limb 166 through central opening 162. Aflexible sleeve 150 is shown in phantom as it optionally encapsulates aportion of limbs 164 and 166 in certain constructions, as described inmore detail below.

FIGS. 2B and 2C more particularly illustrate the formation of a cinchnoose or snare 130 in an improved cinch noose construct or snareassembly 120, having an opening 132. The ends of free filament limbs 134and 136 of the filament are passed through central opening 162, asrepresented by arrows 137 and 139 in FIG. 2B, which draws noose limbs134 and 136 therethrough. Noose 160 is then tightened, as shown in FIG.2C, to form a slidable knot for the snare 130. Alternatively, if asleeve 150, as shown in FIG. 2A, or a sleeve 150′, as shown in FIG. 2C,is not utilized, or if such sleeve is removed after being passed throughtissue to be tensioned, then one or both of free limbs 134, 136 can bepassed through one or both of the openings 161, 163.

Joining together at least the free filament limbs improves suturemanagement and reduces the possibility of suture entanglement or damageby instruments, especially when passed through a cannula. For example, asurgeon or other user need only grasp and pass one sleeve 150 throughthe noose 160 to thereby manipulate the free filament limbs 134, 136 asa single unit.

FIGS. 3A-3D illustrate another exemplary method of forming a snareassembly 220 having a snare 230 and a coaxial sliding neck 235 for usein a surgical repair construct. In this exemplary embodiment, the snare230 is formed from a bifurcated suture filament having a tubular portion237 with a core removed therefrom to form a cannulated portion 239 andfirst and second terminal limbs 234, 236. As shown in FIG. 3B, theterminal limbs 234, 236 can be curled back toward the tubular portion237 to form a loop having an opening 232 that defines the snare 230. Asshown in FIG. 3C, a bore 260 can be formed on a side of the tubularportion 237 and the terminal limbs 234, 236 can be placed into thecannulated tubular portion 239 through the bore 260. Ends of theterminal limbs 234, 236 can be fed through the cannulated portion 239,and as shown in FIG. 3D, the terminal limbs 234, 236 can be pulleddistally (direction A in FIG. 3D) through the tubular portion 237 suchthat the tubular portion 237 is fed through itself. Accordingly, thesnare 230 can be collapsed by tensioning the limbs 234, 236 and/orcoaxial sliding neck 235 in approximately a first direction A, and thesnare 230 can be expanded by applying a force to the snare 230 inapproximately a second, opposite direction B, which pulls the limbs 234,236 towards the snare 230. Passing the filament through itself to form acoaxial sliding neck allows the filament to have a low profile thatminimizes the amount of space the construct consumes in the body andthat minimizes and/or eliminates trauma associated with passing thefilament through tissue.

A person having skill in the art will recognize a number of other waysthat a snare for use in snare assemblies can be created and used inconjunction with the teachings herein. For example, a number ofdifferent sliding knots can be used to form snares, including but notlimited to a Buntline Hitch, a Tennessee Slider, a Duncan Loop, aHangman's Noose, and a coaxial sliding neck. To the extent the slidingknot used to form a snare affects the operation of the snare, forinstance whether a limb is pulled through a knot to change the positionof the knot or a knot is slid along a limb to change the position of theknot, a person skilled in the art would be able to adapt these types ofknots for use with the teachings of the present invention withoutdeparting from the spirit of the present disclosure. As describedherein, unless otherwise designated, a knot used to form a snare ismovable away from the terminal end of the snare assembly to collapse thesnare and towards the terminal end to increase a size of the snare.

The snare assemblies 20, 120, 220 can be made of any suitable flexiblematerial, for instance a filament, including a cannulated filament, abraided filament, and a mono filament. The type, size, and strength ofthe flexible material can depend, at least in part, on the type ofanchor with which it is used, any obstructions through which the snareassembly may pass, and the type of procedure in which it is used. In oneexemplary embodiment the flexible material is a #2 filament (about 23gauge to about 24 gauge), such as an Orthocord™ filament that iscommercially available from DePuy Mitek, Inc or Ethibond™ filamentavailable from Ethicon, Inc. Generally the filament is relatively thinto minimize any trauma to tissue through which it passes. In someembodiments the filament can have a size between about a #5 filament(about 20 gauge to about 21 gauge) and about a #5-0 filament (about 35gauge to about 38 gauge). The Orthocord™ #2 filament can be usefulbecause it has a braided configuration, which allows other components,including the filament itself, to pass through subcomponents of thebraid without causing damage to the filament. Filaments configured toallow for a cannulated configuration, such as by removing a coretherefrom or having a pre-formed cannulated configuration, can also beused. Orthocord™ suture is approximately fifty-five to sixty-fivepercent PDS™ polydioxanone, which is bioabsorbable, and the remainingthirty-five to forty-five percent ultra high molecular weightpolyethylene, while Ethibond™ suture is primarily high strengthpolyester. The amount and type of bioabsorbable material, if any,utilized in the filaments of the present disclosure is primarily amatter of surgeon preference for the particular surgical procedure to beperformed. Further, a length of filaments used to form the snareassemblies 20, 120, 220 can be in the range of about 15 centimeters toabout 125 centimeters, and in one embodiment it can be about 60centimeters.

In embodiments that include a flexible sleeve, such as the embodimentsshown in FIGS. 1, 2A and 2C, the sleeve 50, 150, 150′ can be made from awide variety of biocompatible flexible materials, including a flexiblepolymer or a filament. In one embodiment, the sleeve is made of apolymeric material. In another embodiment, the sleeve is a flexiblefilament, such as a braided suture, for example Ethibond™ #0 filament orOrthocord™ #2 filament, which is typically braided at sixty picks per2.54 centimeters. For use as a sleeve, a more relaxed braid ofapproximately thirty to forty picks per 2.54 centimeters is preferred,more preferably about 36 picks per 2.54 centimeters. If the sleevematerial is formed about a core, preferably that core is removed tofacilitate insertion of the filament limbs, which may themselves beformed of typical suture such as Orthocord™ #0 suture or #2 suturebraided at sixty picks per 2.54 centimeters. Additional convenience canbe provided by perceptible indicators on the sleeve such as differentmarkings, colors, diameters, braid or design patterns, or other tactileor visual indicia, especially if multiple tissue attachments or anchorsare utilized.

A length and diameter of the sleeve 50, 150, 150′ can depend, at leastin part, on the size and configuration of the components of the devicewith which it is used, the obstructions through which the sleeve maypass, and the surgical procedure in which it is used. In any event, thesleeve is typically of a size such that it can pass atraumaticallythrough tissue. In embodiments in which the sleeve is a filament, a sizeof the sleeve can be in the range of about a #5 filament (about 20 gaugeto about 21 gauge) to about a #2-0 filament (about 28 gauge), and in oneembodiment the size can be about a #0 filament (about 26 gauge to about27 gauge). A person having skill in the art will recognize comparablediameter sizes that can be used in instance in which the sleeve is madeof a polymeric or other non-filament material. The sleeve can have alength in the range of about 10 centimeters to about 60 centimeters, andin one embodiment it has a length of about 40 centimeters.

A person having skill in the art will recognize that the configurationsof FIGS. 1-3D are just some options for forming snare assemblies. In theillustrated embodiment the snare assembly is made of a single filament.In other embodiments, however, multiple filaments can be used, forexample by using one filament to create a component that includes asnare, such as a snare linkage, and another filament to form acollapsible loop in place of a terminal end (e.g., terminal end 24 shownin FIG. 1), as described in more detail in U.S. patent application Ser.No. 13/465,288 filed concurrently herewith, and entitled “Systems,Devices, and Methods for Securing Tissue”, the content of which isincorporated by reference herein in its entirety. Other exemplaryembodiments of snare assemblies that can be used in conjunction with theteachings herein are described at least in U.S. patent application Ser.No. 13/218,810 filed Aug. 26, 2011, and entitled “SURGICAL FILAMENTSNARE ASSEMBLIES,” the content of which is also incorporated byreference herein in its entirety.

Embodiments of surgical soft tissue repair devices described hereingenerally couple a snare assembly to a soft anchor. Soft anchors aregenerally flexible in nature and can be formed from a flexible filamentor from a polymeric material in the form of, for example, a sleeve. Suchsoft anchors, which typically are non-metallic, can include one or moreopenings to allow at least a portion of the snare assembly to pass intoand/or through the anchor. Soft anchors can have an unsettled orunstressed configuration that can be used for deployment to the surgicalsite, and an, anchoring configuration that can be used for fixating theanchor following deployment at the surgical site. Manipulation of thesoft anchors can be effective to transition the anchors from the first,unstressed configuration to the second, anchoring configuration. Thetransition of a soft anchor from one configuration to the othertypically alters the dimensions (e.g., the length and/or diameter) ofthe anchor. By way of a non-limiting example, in some repair deviceembodiments a diameter of a soft anchor in its anchoring configuration(i.e., its second diameter) can be in the range of about 10% greater toabout 80% greater than the diameter in the unstressed configuration(i.e., its first diameter). In one embodiment, the second diameter canbe about 20% greater than the first diameter of the soft anchor.Similarly, by way of further non-limiting example, in some repair deviceembodiments a length of a soft anchor in its anchoring configuration(i.e., its second length) can be in the range of about 20% less to about80% less than a length of the soft anchor in its unstressedconfiguration (i.e., its first length). In one embodiment the secondlength can be about 50% less than the first length.

FIG. 4 illustrates one exemplary embodiment of a surgical soft tissuerepair device 310 in which the snare assembly 20 from FIG. 1 is coupledto one embodiment of a soft anchor 312. As shown, the anchor 312 can bea cannulated suture 314 having a central lumen 316 disposedtherethrough. The snare assembly 20 can pass through at least a portionof the central lumen 316 to couple the snare assembly 20 to the anchor312 such that the anchor 312 is at an intermediate location on the snareassembly 20 (i.e., at a location between the first end 22 and theterminal end 24). More particularly, suture 312 can include a pluralityof openings 318, 319 formed therein to accommodate coupling to the snareassembly and actuation of the anchor from the unstressed to theanchoring configuration. In the illustrated embodiment two openings arepresent in proximity to opposite ends of the anchor 312 for passing thesnare assembly into and out of the central lumen 316. One skilled in theart will appreciate that the openings 318, 319 can be located in anumber of different locations. In the illustrated embodiment the firstopening 318 is formed in proximity to a proximal portion 312 p of theanchor 312 and the second opening 319 is formed in proximity to a distalportion 312 d of the anchor 312. As shown, the first and second openings318, 319 face each other, but if the cannulated suture 314 was stretchedout into an approximately straight line, it could be said that theopenings 318, 319 are located on the same side of the soft anchor 312.

As noted above, once deployed in bone the anchor 312 is capable ofmoving between a first, unstressed configuration and a second, anchoringconfiguration. The placement of the soft anchor 312 in bone, as will beexplained below, causes the anchor to be laterally constrained within abore that is formed in bone. When tension is applied to the snareassembly, which is coupled to the soft anchor, the soft anchor deforms.This deformation causes the dimensions of the anchor to be altered. Asthe diameter of the deployed anchor increases within the bore in whichit is deployed, as explained above, the length decreases. The effect ofthe increasing diameter is to create a frictional engagement of the softanchor within the bore and/or fixation of portions of the anchor intobone (particularly cancellous bone), thereby fixating the anchor in boneand allowing tissue attached to the snare assembly to be secured in adesired position.

The anchor 312 can be made of a variety of materials in a variety offorms. In one exemplary embodiment the anchor 312 is formed using asurgical filament, such as a cannulated filament or a braided filament.Alternatively, the anchor 312 can be made from a polymeric material inthe form of a flexible sleeve. The type, size, and strength of thematerials used to form the soft anchor 312 can depend, at least in part,on the other materials that form the snare assembly, the type of tissuein which it will be deployed, and the type of procedure with which itwill be used. In one exemplary embodiment the anchor is formed from a #2filament (about 23 gauge to about 24 gauge), such as an Orthocord™filament that is commercially available from DePuy Mitek, Inc. or anEthibond™ filament that is commercially available from Ethicon, Inc.,Route 22 West, Somerville, N.J. 08876. The cores of these filaments canbe removed to form the cannulated configuration. Orthocord™ suture isapproximately fifty-five to sixty-five percent PDS™ polydioxanone, whichis bioabsorbable, and the remaining thirty-five to forty-five percentultra high molecular weight polyethylene, while Ethibond™ suture isprimarily high strength polyester. The amount and type of bioabsorbablematerial, if any, utilized in the filaments of the present disclosure isprimarily a matter of surgeon preference for the particular surgicalprocedure to be performed.

A length of the anchor when it is in an approximately linear, unfoldedand undeployed configuration can be in the range of about 8 millimetersto about 50 millimeters, and in one embodiment it can be about 20millimeters. Further, a length of the anchor when it is deployed and inits unstressed configuration (FIG. 5A, described below) can be in therange of about 4 millimeters to about 25 millimeters, and in oneembodiment it can be about 10 millimeters and a diameter of the deployedsoft anchor in such a configuration (i.e., a folded configuration) canbe in the range of about 0.5 millimeters to about 5 millimeters, and inone embodiment it can be about 1 millimeter. Still further, a length ofthe anchor when it is deployed and in its anchoring configuration (FIG.5B, described below) can be in the range of about 2 millimeters to about25 millimeters, and in one embodiment it can be about 5 millimeters anda diameter in such a configuration can be in the range of about 1millimeter to about 10 millimeters, and in one embodiment it can beabout 2 millimeters.

A person having skill in the art will recognize a variety of otherconstructions the device 310, the snare assembly 20 (discussed above),and the anchor 312 can have without departing from the spirit of thepresent disclosure. By way of non-limiting examples, the snare assembly20 can be coupled to the anchor 312 at different locations thanillustrated, can pass in and out of the cannulated suture 314 any numberof times, the suture 314 can have a twisted configuration, and openings318, 319 for allowing the snare assembly to pass into the central lumen316 can be relocated to other portions of the anchor 312. A personhaving skill in the art will recognize the way by which the snareassembly 20 is passed through and across the anchor 312 can affect thelook and performance of the second, anchoring configuration. Otheranchors with which the snare assembly 20 can be coupled to and operatedsimilar to manners provided for herein are described at least in U.S.Pat. No. 7,658,751 to Stone et al., the content of which is incorporatedby reference herein in its entirety.

FIGS. 5A-5H illustrate one exemplary method for performing a tissuerepair using the repair construct illustrated in FIG. 4. A surgicalopening can be formed through skin 1000 and a cannula can be passedtherethrough to access a surgical repair site in a manner well known tothose skilled in the art. Although cannulas are often used to define achannel through which the procedure can be performed, the cannula is notshown in FIGS. 5A-5H for ease of illustration. Accordingly, to theextent the figures show components of the systems and devices passingthrough skin 1000, these components would typically be extending throughthe cannula, which itself is passed through the skin 1000. Further,although the devices and methods described herein are particularlyuseful for minimally invasive surgery, such as arthroscopic surgery,they can also be used in open surgical procedures.

As shown in FIG. 5A, the snare assembly 20 can be coupled to the anchor312 by passing the terminal end 24 through the opening 318, through thecentral lumen 316, and out the other opening 319 so that the anchor 312is located at an intermediate location of the snare assembly 20 with thesnare 30 extending from a first side of the anchor 312 and the terminalend 24 extending from the other. A bore 1002 can be formed in a bone1001 and the device 310 shown in FIG. 4 can be inserted into the bore.In the deployed, unstressed configuration shown in FIG. 5A, the anchoris folded essentially in half to assume a U-like shape. Alternatively,the anchor can be delivered in an unfolded, e.g., approximatelystraight, configuration.

One skilled in the art will appreciate that a number of differenttechniques can be used to place the device 310 into the bore. By way ofnon-limiting example, the anchor 312 can be coupled to a distal end of astiff wire or other similar tool or device to position the anchor 312within the bore 1002. The wire can have one or more prongs at its distalend, thereby forming a fork, and the anchor 312 can be wrapped throughone or more of the one or more prongs such that the anchor 312 remainsin its unstressed configuration during insertion. Alternatively, thewire can have a single prong at its distal end such the prong piercesthrough the anchor, similar to a skewer. In other embodiments, the wirecan include one or more slanted cuts on a side of the wire near itsdistal end, and the anchor 312 can be hung into one or more of the oneor more slanted cuts. By way of further non-limiting example, the anchor312 can be located in a device or tool similar to the device 590described below with respect to FIG. 9A and placed in the bore 1002 in asimilar manner. By way of one final non-limiting example, the anchor 312can include a fish tail like the fish tail 617 described below withrespect to FIGS. 10 and 11A-11J and inserted into bone 1001 in a similarmanner.

As shown in FIG. 5B, after the anchor is deployed, tension can beapplied to the snare assembly 20 approximately in a direction C, whichin turn can actuate the anchor 312 to move from its unstressedconfiguration to its anchoring configuration. This tension causesdeformation of the anchor 312 and it substantially bunches and has agreater diameter in the anchoring configuration. In the illustratedembodiment the bunched, anchoring configuration is substantiallyW-shaped for illustrative purposes, but a person skilled in the art willrecognize a number of different configurations that the anchor 312 canhave in the anchoring configuration. In this configuration the anchor312 engages and impinges the walls of the bore 1002, penetratingcancellous bone in some embodiments so that the anchor 312 can besubstantially fixed with respect to the bore 1002. While the overallshape of the anchor in the anchoring configuration will depend, at leastin part, on the way the snare assembly 20 is coupled to the anchor 312,as shown the diameter of the anchor in the second, anchoringconfiguration increases in comparison to the diameter in the unstressedconfiguration, while the length of the anchor in the anchoringconfiguration decreases in comparison to the length of the unstressedconfiguration.

As described herein, the impingement of the anchor, such as the anchor312 and the anchors 412, 512, 612 described below, into the walls of thebore 1002 may be initiated solely by friction between the anchor and thewalls and further helped by varying bone density, which in generalincreases in a direction from the distal end of the bore 1002 to theproximal end. The shape transformation process may also be initiated byintroducing a retaining device against the anchor and applying tensionon the snare against the retaining device.

As shown in FIG. 5C, the terminal end 24 of the snare assembly 20 can bepassed into and through at least a portion of the tendon 1003 detachedfrom the bone 1001. Optionally, a needle or similar tool or device canbe coupled to the terminal end 24 to assist with threading the snareassembly 20 through the tendon 1003. Likewise, other shuttlingtechniques known to a person skilled in the art can also be used to passthe snare assembly through the tendon.

As shown in FIGS. 5D and 5E, a portion of the terminal end 24 can bepassed through the opening 32 of the snare 30 and the snare 30 can becollapsed or dressed in a manner consistent with its snare type. Thus,in the illustrated embodiment the snare 30 can be collapsed by movingthe knot that forms the snare 30 away from the terminal end 24.

As shown in FIG. 5F, tension can be applied to the terminal end 24 bypulling approximately in a direction D, thereby causing the collapsedsnare 30 to slide distally toward the tendon 1003 in a zip line-likemanner until the snare 30 is adjacent to the tendon 1003. This, in turn,can cause the tendon 1003 to move toward and into contact with the bone1001. Alternatively, tension can be applied to the terminal end 24before the snare 30 is dressed and after the snare 30 is adjacent to thetendon 1003, or some combination of the two actions can be used, such aspartially dressing the snare 30 before zip-lining it toward the tendon1003. As shown in FIG. 5F, in embodiments that include the sleeve 50, asthe snare is slid distally toward the tendon, the sleeve 50 can moveproximally, out of the body. The sleeve 50, if included, can be removedat any time, as shown in FIG. 5G for example. Final tensioning can becarried out by applying tension to the terminal end 24, or the sleeve 50if it remains associated with the snare assembly.

As shown in FIG. 5H, one or more half-hitches can be formed proximate tothe collapsed snare to allow for incremental or ratchet-like tensioningand/or to maintain a location of the collapsed snare. After a firsthalf-hitch is formed, the snare assembly 20 can be further tensioned inan incremental or ratchet-like manner by applying tension to the snareassembly 20. The addition of a second or more half-hitches can lock thelocation of the collapsed snare. Excess filament can then be trimmed andremoved to complete the procedure. Other techniques known to thoseskilled in the art can be used to maintain the location of the collapsedsnare, and thus the approximated tissue.

FIG. 6 illustrates another exemplary embodiment of a surgical softtissue repair device 410 in which the snare assembly 20 from FIG. 1 iscoupled to a soft anchor 412. As shown, the anchor 412 can be in theform of suture 414, or another flexible element such as a polymericsleeve, having plurality of openings 416 formed therein with a pluralityof bores 418 extending through the anchor 412 along a length thereof.The soft anchor 412 may be cannulated or non-cannulated. As illustrated,the snare assembly 20 can enter and exit the anchor 412 through theopenings 416 and pass across the anchor 412 through the bores 418 tocouple the snare assembly 20 to the anchor 412 such that the anchor 412is at an intermediate location on the snare assembly 20. The openings416 and bores 418 can be in a number of different configurations. In theillustrated embodiment, there are twelve openings 416 and six bores 418,with at least some of the bores 418 extending transversely between twoopenings 416. As shown, each opening 416 has a complimentary openingthrough the other side of the anchor 412, and a bore 418 extends betweenthe opposed paired openings 416. Furthermore, as shown, the snareassembly 20 can be passed across the anchor 412 symmetrically, and thusthe opposed paired openings 416 having a bore 418 extending therebetweencan have a mirror-image counterpart opposed paired openings 416 and bore418 extending therebetween. Once deployed, the anchor 412 is capable ofmoving between an unstressed configuration and an anchoringconfiguration.

The anchor 412 can be made of a variety of materials, but in oneexemplary embodiment the anchor 412 is formed using a surgical filament,such as a cannulated filament, a braided filament, or a mono filament.Alternatively, the anchor 412 can be made from a polymeric material inthe form of a flexible sleeve. The type, size, and strength of thefilament can depend, at least in part, on the other materials that formthe snare assembly, the type of tissue in which it will be deployed, andthe type of procedure with which it will be used. In one exemplaryembodiment the anchor is formed from a #2 filament (about 23 gauge toabout 24 gauge), such as an Orthocord™ filament that is commerciallyavailable from DePuy Mitek, Inc. or an Ethibond™ filament that iscommercially available from Ethicon, Inc.

A length of the anchor when it is in an approximately linear, unfoldedand undeployed configuration can be in the range of about 8 millimetersto about 50 millimeters, and in one embodiment it can be about 20millimeters. Further, a length of the anchor when it is deployed and inits unstressed configuration (FIG. 7A, described below) can be in therange of about 4 millimeters to about 25 millimeters, and in oneembodiment it can be about 10 millimeters and a diameter of the deployedsoft anchor in such a configuration (i.e., a folded configuration) canbe in the range of about 0.5 millimeters to about 5 millimeters, and inone embodiment it can be about 1 millimeter. Still further, a length ofthe anchor when it is deployed and in its anchoring configuration (FIG.7B, described below) can be in the range of about 2 millimeters to about10 millimeters, and in one embodiment it can be about 5 millimeters anda diameter in such a configuration can be in the range of about 1millimeter to about 10 millimeters, and in one embodiment it can beabout 2 millimeters.

A person having skill in the art will recognize a variety of otherconstructions the device 410, the snare assembly 20 (discussed above),and the anchor 412 can have without departing from the spirit of thepresent disclosure. By way of non-limiting example, any number ofopenings and bores, and configurations thereof, can be used, although insome embodiments the number of bores can be in the range of about 2bores to about 10 bores, and in one embodiment there can be 4 boreswhile in another embodiment there can be 6 bores. Further, the anchor412 can be configured to allow the snare assembly 20 to pass through anyportion thereof, including in an asymmetric and non-transverse manner,depending, at least in part, on other components of the device 410 andthe desired second, anchoring configuration, among other factors. Aperson having skill in the art will recognize that the way in which thesnare assembly 20 is passed through and across the anchor 412 can affectthe look and performance of the anchoring configuration. Other anchorswith which the snare assembly 20 can be coupled to and operated similarto manners provided for herein are described at least in literaturerelated to the Y-KNOT® suture anchor systems that are commerciallyavailable from CONMED, 525 French Road, Utica, N.Y. 13502, the contentof which is incorporated by reference herein in its entirety.

FIGS. 7A-7H illustrate one exemplary method for performing a tissuerepair using the repair construct illustrated in FIG. 6. A surgicalopening can be formed through skin 1000 and a cannula can be passedtherethrough to access a surgical repair site according to well knowntechniques. Similar to FIGS. 5A-5H, although cannulas are often used todefine a channel through which the procedure can be preformed, thecannula is not shown in FIGS. 7A-7H for ease of illustration.Accordingly, to the extent the figures show components of the systemsand devices passing through skin 1000, these components would typicallybe extending through the cannula, which itself is passed through theskin 1000.

As shown in FIG. 7A, the snare assembly 20 can be coupled to the anchor412 by passing the terminal end 24 through and across the openings 416and the bores 418 formed therein so that the anchor 412 is located at anintermediate location of the snare assembly 20 with the snare 30extending from a first side of the anchor 412 and the terminal end 24extending from the other. A bore 1002 can be formed in a bone 1001 andthe device 410 shown in FIG. 6 can be inserted into the bore, forinstance in a folded configuration as shown or in an unfolded, e.g.,approximately straight, configuration. A number of different techniquescan be used to place the device 410 into the bore, including techniquesknown to those skilled in the art, those described above with respect tothe anchor 312, and those described below with respect to FIGS. 9A, 10,and 11A-11J. By way of non-limiting example, a device having a pluralityof prongs can be used to insert the anchor 412 such that the prongsmaintain the anchor 412 in its first, unstressed configuration duringinsertion.

As shown in FIG. 7B, after the anchor is deployed in bone, tension canbe applied to the snare assembly 20 approximately in a direction E,which in turn can actuate the anchor 412 to move from its unstressedconfiguration to its anchoring configuration. This tension causesdeformation of the anchor 412 and it substantially bunches and has agreater diameter in the anchoring configuration. In the illustratedembodiment the bunched, anchoring configuration is substantiallyfist-like or spherical for illustrative purposes, but a person skilledin the art will recognize a number of different configurations that theanchor 412 can have in the anchoring configuration. In thisconfiguration the anchor 412 engages and impinges the walls of the bore1002 in its anchoring configuration, penetrating cancellous bone in someembodiments so that the anchor 412 can be substantially fixed withrespect to the bore 1002. While the overall shape of the anchor in theanchoring configuration will depend, at least in part, on the way thesnare assembly 20 is coupled to the anchor 412, as shown the diameter ofthe anchor in the second, anchoring configuration increases incomparison to the diameter in the unstressed configuration, while thelength of the anchor in the anchoring configuration decreases incomparison to the length of the unstressed configuration.

The device 410 can then be operated in a manner similar to as describedwith respect to FIGS. 5C-5H. Thus, at least a portion of the terminalend 24 can be passed through at least a portion of the tendon 1003 andthrough the opening 32 in the snare 30 and the snare 30 can be collapsedor dressed, for instance by moving the knot that forms the snare 30 awayfrom the terminal end 24. The snare 30 can be slid distally toward thetendon 1003 by applying tension approximately in a direction F, whichcan result in the snare 30 being adjacent to the tendon 1003 and thetendon 1003 moving towards the bone 1001. Final tensioning and removalof the sleeve 50, if used, can occur, and one or more half-hitches canbe formed proximate to the collapsed snare 30 to allow for incrementalor ratchet-like tensioning and/or to maintain a location thereof. Excessfilament can then be trimmed and removed to complete the procedure.

FIG. 8 illustrates yet another exemplary embodiment of a surgical softtissue repair device 510 in which the snare assembly 20 from FIG. 1 iscoupled to the anchor 512. As shown, the anchor 512 can be a crochetedsuture 514 having a plurality of openings 516 defined between filamentlimbs along a length thereof. The snare assembly 20 can be wovenback-and-forth across the suture 514 any number of times to couple thesnare assembly 20 to the anchor 512 such that the anchor 512 is at anintermediate location on the snare assembly 20. In the illustratedembodiment the snare assembly is passed across the suture 514 at aproximal end 514 p of the suture 514 and is passed back-and-forth acrossthe suture 514 five more times, each time being more distal of the next,before being looped back from a distal end 514 d to the proximal end 514p and being passed across the suture 514 one last time at the proximalend 514 p.

The anchor 512 can be made of a variety of materials, but in oneexemplary embodiment the anchor 512 is formed using a surgical filament,such as a cannulated filament, a braided filament, or a mono filament.The type, size, and strength of the filament can depend, at least inpart, on the other materials that form the snare assembly, the type oftissue in which it will be deployed, and the type of procedure withwhich it will be used. In one exemplary embodiment the anchor is formedfrom a #2 filament (about 23 gauge to about 24 gauge), such as anOrthocord™ filament that is commercially available from DePuy Mitek,Inc. or an Ethibond™ filament that is commercially available fromEthicon, Inc.

The length of the anchor 512 when it is deployed in bone and in itsunstressed configuration (FIG. 9A, described below) can be in the rangeof about 5 millimeters to about 50 millimeters, and in one embodiment itcan be about 25 millimeters. The diameter of anchor 512 in such aconfiguration can be in the range of about 0.5 millimeters to about 5millimeters, and in one embodiment it can be about 1 millimeter. Whenthe anchor 512 is deployed and in its anchoring configuration (FIG. 9B,described below), its length can be in the range of about 2 millimetersto about 10 millimeters, and in one embodiment it can be about 5millimeters. The diameter of the deployed anchor 512 in its anchoringconfiguration can be in the range of about 1 millimeter to about 10millimeters, and in one embodiment it can be about 2 millimeters.

A person having skill in the art will recognize a variety of otherconstructions the device 510, the snare assembly 20 (discussed above),and the anchor 512 can have without departing from the spirit of thepresent disclosure. By way of non-limiting example, the snare assembly20 can be passed across the anchor 514 any number of times at any numberof locations, and not necessarily in a consecutive downstream orupstream order. A person having skill in the art will also recognizethat the way by which the snare assembly 20 is passed through and acrossthe anchor 512 can affect the look and performance of the second,anchoring configuration. Other anchors to which the snare assembly 20can be coupled to and operated similar to manners provided for hereinare described at least in U.S. Patent Application Publication No.2011/0022083 filed Jul. 24, 2009, and entitled “METHODS AND DEVICES FORREPAIRING AND ANCHORING DAMAGED TISSUE,” the content of which isincorporated by reference herein in its entirety.

FIGS. 9A-9H illustrate one exemplary method for performing a tissuerepair using the repair construct illustrated in FIG. 8. A surgicalopening can be formed through skin 1000 and a cannula can be passedtherethrough to access a surgical repair site according to well knowntechniques. Similar to FIGS. 5A-5H, although cannulas are often used todefine a channel through which the procedure can be preformed, thecannula is not shown in FIGS. 9A-9H for ease of illustration.Accordingly, to the extent the figures show components of the systemsand devices passing through skin 1000, these components would typicallybe extending through the cannula, which itself is passed through theskin 1000.

As shown in FIG. 9A, the snare assembly 20 can be coupled to the anchor512 in a manner similar to that described above with respect to FIG. 8.This construction is such that the anchor 512 is located at anintermediate location of the snare assembly 20 with the snare 30extending from a first side of the anchor 512 and the terminal end 24extending from the other. A bore 1002 can be formed in a bone 1001 andthe device 510 shown in FIG. 8 can be inserted into the bore. A numberof different techniques can be used to place the device 510 into thebore, including techniques known to those skilled in the art. By way ofnon-limiting example, an insertion device 590 having a body 592 defininga cavity 594 therein and a piston 596 disposed within the cavity 594 canbe inserted to a distal end 1002 d of the bore 1002 so that the anchor512 is located distally within the bore 1002, as shown in FIG. 9A. Thedevice 590 can also include one or more features to manage the snareassembly 30, including, by way of non-limiting example, a central lumen598 in the piston 596 for receiving the snare assembly 20. The body 592can be removed while the piston 596 is left stationary to hold theanchor 512 in place, and then after the body 592 is removed, the piston596 can be removed, thereby leaving the anchor 512 disposed in the bore1002. Such a configuration allows unintended movement of the anchor 512to be minimized or eliminated, thereby reducing the possibility of apremature deployment to the second, anchoring configuration. In analternative embodiment, the device 590 can be located adjacent to aproximal end 1002 p of the bore 1002 and the piston 596 can be actuatedto move the anchor 512 from the device 590 and into the bore 1002. Stillfurther, delivery options discussed above with respect to the anchors312, 412 can also be used with the anchor 512, as well as othertechniques known to those skilled in the art.

With reference to FIG. 9B, once the anchor 512 is disposed in bore 1002tension can be applied to the snare assembly 20 approximately in adirection G. With the anchor constrained within bore 1002, this forceactuates the anchor 512 so that it transitions from its unstressedconfiguration to its anchoring configuration. This tension causesdeformation of the anchor 512 and it substantially bunches and has agreater diameter in the anchoring configuration. In the illustratedembodiment the bunched, anchoring configuration substantially fist-likeor spherical for illustrative purposes, but a person skilled in the artwill recognize a number of different configurations that the anchor 512can have in the anchoring configuration. In this configuration theanchor 512 engages and impinges the walls of the bore 1002, penetratingcancellous bone in some embodiments so that the anchor 512 can besubstantially fixed with respect to the bore 1002. While the overallshape of the anchor in the anchoring configuration will depend, at leastin part, on the way the snare assembly 20 is coupled to the anchor 512,as shown the diameter of the deployed anchor in 512 the anchoringconfiguration increases in comparison to the anchor diameter of theunstressed configuration, while the length of the deployed anchor in theanchoring configuration decreases in comparison to the diameter of theanchor in the unstressed configuration.

As described above, the impingement of the anchor into the walls of thebore 1002 may be initiated solely by friction between the anchor and thewalls and further helped by varying bone density, and further, the shapetransformation process may also be initiated by introducing a retainingdevice against the anchor and applying tension on the snare against theretaining device. In some embodiments, the piston 596 can serve as theretaining device. For example, after the body 592 is retracted, thepiston 596 can be kept in place and the snare assembly 20 can betensioned against the piston 596, thus causing the anchor 512 to move tothe anchoring configuration. The piston 596 can then be removed from thesurgical site. In such embodiments the lumen 598 of the piston 596 canbe small enough so as not to accommodate the snare assembly 20 and theanchor 512 together.

Following deployment of the anchor 512 from its first, unstressedconfiguration to its second, anchoring configuration, the device 510 canbe operated in a manner similar to that described with respect to FIGS.5C-5H. Thus, at least a portion of the terminal end 24 can be passedthrough at least a portion of the tendon 1003 and through the opening 32in the snare 30 and the snare 30 can be collapsed or dressed, forinstance by moving the knot that forms the snare 30 away from theterminal end 24. The snare 30 can be slid distally toward the tendon1003 by applying tension approximately in a direction H, which canresult in the snare 30 being adjacent to the tendon 1003 and the tendon1003 moving toward the bone 1001. Final tensioning and removal of thesleeve 50, if used, can occur, and one or more half-hitches can beformed proximate to the collapsed snare 30 to allow for incremental orratchet-like tensioning and/or to maintain a location thereof. Excessfilament can then be trimmed and removed to complete the procedure.

FIG. 10 illustrates still another exemplary embodiment of a surgicalsoft tissue repair device 610 in which the snare assembly 20 of FIG. 1is coupled to soft anchor 612. As shown, the anchor 612 is of a similarnature as the anchor 512, and thus it can include the same featuresdiscussed above with respect to the anchor 512. Accordingly, it can be acrocheted suture 614 having a plurality of openings 616 defined betweenfilament limbs along a length thereof, with the snare assembly beingwoven back-and-forth across the suture 614 in a manner similar asdescribed above such that the anchor 612 is at an intermediate locationon the snare assembly 20. The anchor 612 includes a fish tail 617 at adistal end 614 d of the suture 614. The fish tail 617 can be used toassist with inserting the anchor 612 to a surgical site, as discussed ingreater detail below. In particular, fish tail 617 can assist innavigating the device through and around obstructions and variousnon-linear paths in the body. As shown, a needle 619 or other similartool or device can optionally be coupled to the suture 612 to assistwith threading the fish tail 617 through obstructions, such as skin andtissue.

The materials and dimensions of the device 610 can likewise be similarto those discussed above with respect to the device 510, with the fishtail 617 being part of the suture 614. The length of the fish tail 617can depend, at least in part, on the dimensions of the rest of thesuture 614, other components with which it is being used, and the typeof procedures with which it is being used. The fish tail 617 can have alength in the range of about 5 centimeters to about 100 centimeters, andin one embodiment a length of the fish tail is about 40 centimeters. Aperson having skill in the art will recognize a variety of otherconstructions the device 610, the snare assembly 20 (discussed above),and the anchor 612 can have without departing from the spirit of thepresent disclosure. Further, a person having skill in the art willrecognize that a fish tail similar to the fish tail 617 can beincorporated in various other anchor embodiments, including but notlimited to the anchors 312, 412, and 512 provided herein. The use of thefish tail to position such anchors would occur in a manner similar tothe manner described below with respect to FIGS. 11A-11J.

FIGS. 11A-11J illustrate one exemplary method for performing a tissuerepair using the repair construct illustrated in FIG. 10. A surgicalopening can be formed through skin 1000 and a cannula can be passedtherethrough to access a surgical repair site according to well knowntechniques. Similar to FIGS. 5A-5H, although cannulas are often used todefine a channel through which the procedure can be preformed, thecannula is not shown in FIGS. 11A-11J for ease of illustration.Accordingly, to the extent the figures show components of the systemsand devices passing through skin 1000, these components would typicallybe extending through the cannula, which itself is passed through theskin 1000.

As shown in FIG. 11A, the snare assembly 20 can be coupled to the anchor612 in the same manner as described above with respect to FIG. 9A.Insertion of the device 610, however, can be different because of thefish tail 617. In one exemplary embodiment for insertion of the device610 to a surgical site, a bore 1002 is formed fully through the bone1001 and the fish tail 617 is used as a shuttle to bring the anchor 612to the desired location. In the illustrated embodiment the fish tail 617passes through a top layer of skin 1000, through the bore 1002, and outof a bottom layer of skin 1000. As shown in FIG. 11B, tension can beapplied to the fish tail 617 in approximately a direction J to pull theanchor 612 through the bore 1002 and to the desired location. The snareassembly 20 can be used to counteract the force applied by the fish tail617 by delivering a force in a direction approximately opposite to thedirection J to assist in placement of the device 610. Although in theillustrated embodiment the fish tail 617 extends through the bottomlayer of skin 1000, in other embodiments it can remain in the body butbe just distal of the bore 1002, which still allows tension to beapplied thereto to help shuttle the anchor 612 to the desired location.

The device 610 can then be utilized in a manner similar to thatdescribed with respect to FIGS. 9B-9H. Thus, tension can be applied tothe snare assembly 20 approximately in a direction K to move the anchorfrom its unstressed configuration to its anchoring configuration. Thistension causes deformation of the anchor 612 and it substantiallybunches and has a greater diameter in the anchoring configuration.Again, in the illustrated embodiment the bunched, anchoringconfiguration is substantially fist-like or spherical for illustrativepurposes, but a person skilled in the art will recognize a number ofdifferent configurations that the anchor 612 can have in the anchoringconfiguration. When the anchor 612 is deployed and in its anchoringconfiguration, it typically resides just distal to bore 1002, on theside of the bore adjacent to the bottom layer of tissue. At least aportion of the terminal end 24 can be passed through at least a portionof the tendon 1003 and through the opening 32 in the snare 30 and thesnare 30 can be collapsed or dressed, for instance by moving the knotthat forms the snare 30 away from the terminal end 24. The snare 30 canbe slid distally toward the tendon 1003 by applying tensionapproximately in a direction L, which can result in the snare 30 beingadjacent to the tendon 1003 and the tendon 1003 moving toward the bone1001. Final tensioning and removal of the sleeve 50, if used, can occur,and one or more half-hitches can be formed proximate to the collapsedsnare 30 to allow for incremental or ratchet-like tensioning and/or tomaintain a location thereof. Excess filament can then be trimmed andremoved to complete the procedure. The fish tail 617 can also be trimmedand removed. Although removal of the fish tail 617 is illustrated inFIG. 11D, such removal can occur at any time after the anchor 612 isshuttled to its desired location.

A person skilled in the art will recognize a number of differentmodifications that can be made to the soft anchor procedures discussedherein without departing from the spirit of the invention. By way of onenon-limiting example, although the embodiments herein illustrate thesnare assembly 20 passing through tissue at one location, in otherembodiments, it can pass through two or more locations and/or two ormore tissues. By way of further non-limiting example, the snare assembly20 can be coupled to tissue using a variety of techniques, for instancewrapping a portion of the snare assembly 20 around the tissue. By way ofstill a further non-limiting example, a snare 30 can be passed throughtissue instead of or in addition to passing the terminal end 24 throughtissue. A pin or other fixation element can be placed across any coaxialsliding neck of the snare to prevent unintentional collapse in such anembodiment, or could be included in any snare assembly embodiment forextra precaution. Still further, a person having skill in the art willrecognize that the order of at least some of the method steps providedherein can be altered without departing from the spirit of the presentdisclosure.

Additionally, the procedures discussed with respect to FIGS. 4-11G arejust some forms of procedures that can be performed in conjunction withsystems, devices, and methods disclosed herein. A person skilled in theart will recognize a number of other ways that the disclosed systems,devices, and methods can be used in various other configurations andtypes of surgical procedures. For instance, the systems, devices, andmethods disclosed herein can easily be adapted to be used in conjunctionwith three or more components, such as multiple tissues and a bone orthree or more soft tissues. Some non-limiting examples of other systems,devices, assemblies, constructs, and surgical procedures with which thepresent systems, devices, and methods can be used are described in U.S.patent application Ser. No. 13/218,810 filed Aug. 26, 2011, and entitled“SURGICAL FILAMENT SNARE ASSEMBLIES,” and in U.S. patent applicationSer. No. 13/465,288 filed concurrently herewith, and entitled “Systems,Devices, and Methods for Securing Tissue” the content of which waspreviously incorporated by reference herein in their entireties.

One skilled in the art will appreciate further features and advantagesof the invention based on the above-described embodiments. Accordingly,the invention is not to be limited by what has been particularly shownand described, except as indicated by the appended claims. Further,although the systems, devices, and methods provided for herein aregenerally directed to surgical techniques, at least some of the systems,devices, and methods can be used in applications outside of the surgicalfield. All publications and references cited herein are expresslyincorporated herein by reference in their entirety.

What is claimed is:
 1. A surgical soft tissue repair device, comprising:a soft anchor configured to be fixated in bone and formed of a flexibleconstruct with a plurality of openings formed therein, the soft anchorhaving an unstressed configuration with a first length and a firstdiameter; and a snare assembly having a collapsible snare at one endthereof and at least one elongate filament extending therefrom, theelongate filament having a terminal end opposite the collapsible snare,the snare assembly being coupled to the soft anchor by the filamentpassing through the plurality of openings such that the soft anchor isat an intermediate location on the elongate filament between thecollapsible snare and the terminal end, wherein the soft anchor andsnare are configured such that the soft anchor is reconfigurable fromthe unstressed configuration to an anchoring configuration by theapplication of tension to the filament when the soft anchor is disposeda distance away from the collapsible snare, the soft anchor and snarebeing further configured such that the snare remains a distance awayfrom the soft anchor when no object is disposed therebetween for theduration of tension application to reconfigure the soft anchor to theanchoring configuration, and any soft anchor coupled to the snareassembly is disposed separate from the collapsible snare, the softanchor having in the anchoring configuration a second length that isless than the first length and a second diameter that is greater thanthe first diameter.
 2. The device of claim 1, wherein the soft anchor isa cannulated suture with a central lumen.
 3. The device of claim 2,wherein the plurality of openings include a first opening on a distalportion of the soft anchor and a second opening on a proximal portion ofthe soft anchor, the first and second openings communicating with thecentral lumen.
 4. The device of claim 3, wherein the filament passesinto the second opening, through the lumen, and out of the firstopening.
 5. The device of claim 3, wherein the first and second openingsare on the same side of the soft anchor.
 6. The device of claim 1,wherein the soft anchor includes a plurality of transverse boresextending therethrough along the length of the soft anchor, and theplurality of openings include opposed paired openings with each opposedpaired opening communicating with one of the transverse bores.
 7. Thedevice of claim 6, wherein the soft anchor includes at least fourtransverse bores and the filament passes into and out of each transversebore through the opposed paired openings.
 8. The device of claim 1,wherein the soft anchor is a crocheted suture anchor and the filamentextends through openings defined between filament limbs of the crochetedsuture anchor along the length thereof.
 9. The device of claim 1,wherein the second diameter is at least about 20% greater than the firstdiameter.
 10. The device of claim 1, wherein the snare assembly isformed of a double filament loop such that the filament has first andsecond filament limbs.
 11. The assembly of claim 1, further comprising aflexible sleeve removably encapsulating at least a portion of thefilament.
 12. A surgical soft tissue repair device, comprising: a softanchor configured to be fixated in bone and formed of a flexibleconstruct with a plurality of openings formed therein, the soft anchorhaving an unstressed configuration with a first length and a firstdiameter; and a snare assembly formed by an elongate filament, the snareassembly having a first terminal end at which a collapsible snare isdisposed and a second terminal end, opposed to the first terminal end,at which the elongate filament terminates, the collapsible snare beingformed by a first portion of the elongate filament passing into a secondportion of the elongate filament such that a leading end of the firstportion does not pass out of the second portion, and the snare assemblybeing coupled to the soft anchor by the elongate filament passingthrough the plurality of openings such that the soft anchor is at anintermediate location on the elongate filament between the collapsiblesnare and the second terminal end, wherein the soft anchor and snare areconfigured such that the soft anchor is reconfigurable from theunstressed configuration to an anchoring configuration by theapplication of tension to the filament, the soft anchor having in theanchoring configuration a second length that is less than the firstlength and a second diameter that is greater than the first diameter.13. The device of claim 12, wherein the second portion of the elongatefilament further comprises a cannulated portion configured to receivethe first portion of the elongate filament therein.
 14. The device ofclaim 13, wherein the cannulated portion is formed by a tubular sectionof the second portion of the elongate filament having a core removedtherefrom.
 15. The device of claim 12, wherein the soft anchor is acannulated suture with a central lumen.
 16. The device of claim 15,wherein the plurality of openings include a first opening on a distalportion of the soft anchor and a second opening on a proximal portion ofthe soft anchor, the first and second openings communicating with thecentral lumen.
 17. The device of claim 16, wherein the filament passesinto the second opening, through the lumen, and out of the firstopening.
 18. The device of claim 16, wherein the first and secondopenings are on the same side of the soft anchor.
 19. The device ofclaim 12, wherein the soft anchor includes a plurality of transversebores extending therethrough along a length of the soft anchor, and theplurality of openings includes opposed paired openings with each opposedpaired opening communicating with one of the transverse bores.
 20. Thedevice of claim 19, wherein the soft anchor includes at least fourtransverse bores and the elongate filament passes into and out of eachtransverse bore through the opposed paired openings.
 21. The device ofclaim 12, wherein the soft anchor is a crocheted suture anchor and thefilament extends through openings defined between filament limbs of thecrocheted suture anchor along the length thereof.
 22. The device ofclaim 12, wherein the snare assembly is formed of a double filament loopsuch that the elongate filament has first and second filament limbs. 23.The device of claim 12, further comprising a flexible sleeve removablyencapsulating at least a portion of the elongate filament.
 24. Asurgical soft tissue repair device, comprising: a soft anchor configuredto be fixated in bone and formed of a flexible construct with aplurality of openings formed therein, the soft anchor having anunstressed configuration with a first length and a first diameter; and asnare assembly formed by an elongate filament, the snare assembly havinga first terminal end at which a collapsible snare is disposed and asecond terminal end, opposed to the first terminal end, at which theelongate filament terminates, the collapsible snare being formed by afirst portion of the elongate filament passing into a second portion ofthe elongate filament, and the snare assembly being coupled to the softanchor by the elongate filament passing through the plurality ofopenings such that the soft anchor is at an intermediate location on theelongate filament between the collapsible snare and the second terminalend, the elongate filament between the intermediate location and thesecond terminal end being disposed outside of the elongate filament,wherein the soft anchor and snare are configured such that the softanchor is reconfigurable from the unstressed configuration to ananchoring configuration by the application of tension to the filament,the soft anchor having in the anchoring configuration a second lengththat is less than the first length and a second diameter that is greaterthan the first diameter.
 25. The device of claim 24, wherein the secondportion of the elongate filament further comprises a cannulated portionconfigured to receive the first portion of the elongate filamenttherein.
 26. The device of claim 24, wherein the soft anchor is acannulated suture with a central lumen.
 27. The device of claim 26,wherein the plurality of openings include a first opening on a distalportion of the soft anchor and a second opening on a proximal portion ofthe soft anchor, the first and second openings communicating with thecentral lumen.
 28. The device of claim 27, wherein the filament passesinto the second opening, through the lumen, and out of the firstopening.
 29. The device of claim 24, wherein the soft anchor is acrocheted suture anchor and the filament extends through openingsdefined between filament limbs of the crocheted suture anchor along thelength thereof.
 30. The device of claim 24, further comprising aflexible sleeve removably encapsulating at least a portion of theelongate filament.